SL.NO.

CONTENT

1 INTRODUCTION

2 TERMMINOLOGIES

3 CONTENT

A. FAMILY NURSING

 Definition of Family
 Definition and Meaning of Family Health Nursing
 Views on Family
 Objectives of Family Health Nursing
 Goals of Family Health Nursing
 Principles of Family Health Nursing
 Advantages of Family Health Nursing
 Disadvantages of Family Health Nursing
 Range of Family Health Nursing
 Approaches to Family Nursing Practice
 Steps in Family Health Nursing
 Family Health Nursing Process
 Nurse’s Responsibility in Family Health Care
 Barriers to family Health Care
 Challenges For Family Nursing

B. HOME NURSING

 Definition
 Unique Aspects of Home Health Nursing
 The Home Health Care System
 Roles of the Home Health Nurse
 Perspectives of Home Care Clients
 Selected Dimensions of Home Health Nursing
 Applying the Nursing Process in the Home
 The Future OF Home Health Care

4 CONCLUSION

5 JOURNAL ABSTRACT

6 BIBLIOGRAPHY

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FAMILY NURSING AND HOME NURSING

INTRODUCTION

Family
The family is often called the basic social institution because of its important functions
of procreation and socialization and because it is found, in some forms in all societies.
Family is a term used in everyday language whose meaning is cognate with the
culturally and historically specific social practices to which it refers. The family as a
universal social institution refers to a distinctive characteristics of the social life of
particular culture and epochs. Its activity and their effects on the maintenance of the
social structure of the society, of which it is a part, concentrating on biological and
demographic features. The structure of the family varies from society to society. The
smallest family unit is known as nuclear family and consists of a husband and wife and
their immature offspring .Units larger than the nuclear family are usually known as
extended families.

Family Health Nursing

Family nursing refers to nursing care that is holistically directed toward the
whole family as well as to individual members.

“Family health nursing is the practice of nursing directed towards maximizing

the health and wellbeing of all individuals within in a family system. It incorporates two
views of family, family as a unit of care and family as a contact. Family health nursing
views the family as a system existing within larger system. Levels of intervention are
the individuals the personal, the family system, and the environmental level. The goals
of the family health nursing include optimal functioning for the individual and for the
family as a unit.”

Home Health Nursing

Historically, home care considered primarily of nurses providing private duty care
in clients’ homes and care of the ill by their own family members. However the delivery
of professional nursing services in home settings has increased in frequency, scope and
complexity in the past two decades. A number of factors have contributed to this trend,
among them rising health care costs, an aging population, and a growing emphasis on
managing chronic illness and stress, preventing illness, and enhancing the quality of
life. In the not- too- distant past, home health care occurred at the end of the client care
continuum- that is, after discharge from an acute care facility. Today the trend is
changing to use of home health care services to avoid hospitalization.
Home nursing care is one of the fastest growing sectors of the health care system.
Factors that have contributed to the growth of home health care include

 The increase in the older population, who are frequent recipients of home care.
 Third party payers who favour home care to control costs.
 The ability of agencies and institutions to successfully deliver high technology
services in the home.

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  Consumers who prefer to receive care in the home rather than in an institutio

TERMMINOLOGY

Baccalaureate : An examination intended to qualify successful candidates

for higher education, the university degree of Bachelor

ANCC : American Nurses Credentialing Center

Hospice nursing : An interdisciplinary program of palliative care and

supportive services that addresses the physical, spiritual,
social, and economic needs of terminally ill patients and
their families. This care may be provided in the home or
hospice center.

Home Assessment : An evaluation of the home environment of person with

disability, usually by an occupational therapist or Home care
specialist, for purposes of identifying Architectural barriers and
safety hazards and Recommending modifications or devices for
improving mobility, safety, and independent function

Terminal illness : An illness that, because of its nature, can be expected to

Cause the patient to die. Usually a chronic disease for which
there is no known cure.

Procreation : The act or state of conceiving and giving birth to an infant,

reproduction

Accreditation : The voluntary process of recognizing that a facility or

institution has met established standards, Official
recognition given to an institution

Appraisal : A formal evaluation of the performance of an employee over

a particular period
Accountability : Responsibility of health care professionals for the actions
and judgments involved in patient care.

Therapeutic Recreation: A specialized field within recreation whose specialists

plan and direct recreational activities for patients
recovering from physical or mental illness or who are
attempting to cope with a permanent or temporary
disability

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 B. HOME NURSING

DEFINITION OF HOME NURSING

The delivery of nursing services in the home has been called a variety of terms,
including home health nursing, home care nursing, and visiting nursing. Home
health care includes the services and products provided to the clients in their homes that
are needed to maintain, restore, or promote their physical, psychological and social
wellbeing. The focus of home health nursing is individuals and their families. This
differs somewhat from the focus of the community health nursing, which focuses on
individuals, families and groups.

UNIQUE ASPECTS OF HOME HEALTH NURSING

Home care nurses must function independently in a variety of unfamiliar home

settings and situations. Because the home is the family’s territory, power and control
issues and delivering nursing care differ from those in the institution. For example,
entry into a home is granted, not assumed, the nurse must therefore establish trust and
rapport with the client and family. Health care that is provided is often given with other
family members present. Families also may feel more free to question advice, to ignore
directions, to do things differently, and to set their own priorities and schedules.

Home health nurses have identified significant advantages in caring for

individuals and families in the home. The home setting is intimate, this intimacy fosters
familiarity, sharing connections, and caring between clients, families and their nurse.
Behaviours are more natural, cultural beliefs and practices are more visible and
multigenerational interactions tend to be displayed.

Home health nurses have also identified issues that negatively affect care in the
home. More than any care providers, these nurses have first hand knowledge and
experience about the burden of care giving. In the interest of cutting health care costs,
policy makers, third party payers, and medical providers are placing increasingly
complex responsibilities on clients’ families and significant other(s). Care giving
demands may go on for months or years, placing the caregivers themselves (many of
whom are elders) at risk for physiologic and psycologic problems. Additionally, nurses
enter homes where the living conditions and support systems may be inadequate.

ROLES OF THE HOME HEALTH NURSE

Historically, nurses who provided direct services in the home were strong
generalists who focused on long term preventive, educational, remedial and
rehabilitative outcomes. Today many health nurses are generalists or specialists
possessing high technology skills that were formerly used only in acute care settings.
For example the nurses provide a variety of intravenous therapies in the home setting

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and monitor clients who are dependent on technologically complex medical equipment,
such as ventilators and central lines. These nurses collaborate with physicians and other
health care professionals in providing care.

Major roles of the home health nurse are:-

 Advocate
 Caregiver
 Educator
 Case Manager or Coordinator

 Advocate

Advocacy begins in the first visit. The nurse explores and supports the client’s
choices in health acre, all viable options are considered. Advocacy includes having
discussion about the client’s rights, advance medical directives, living wills and durable
power of attorney for health care. It also usually involves assistance to access
community resources, to make informed decisions, to recognize and cope with
necessary changes in lifestyle, to negotiate medical insurance, and to understand ways
to effectively use the complex medical system. Advocacy can be a particular challenge
when family members’ or other caregivers views differ from those of the client. In the
event of conflict, the nurse, being the client’s primary advocate, ensures that the client’s
rights and desires are upheld.

 Caregiver

The home health nurse’s major role as caregiver is to assess and diagnose the
client’s actual and potential health problems, plan care, and evaluate the client’s
outcomes. Direct personal care activities such as bathing, changing linens, feeding, and
light housekeeping activities to maintain a clean and safe home environment are usually
provided by a family member or a home health aide arranged by the nurse. The home
health nurse, however, will provide direct care for specific procedures and treatment
such as ostomy care; wound care, intravenous therapy, and so on according to agency
policies and practices. Much of the home health nurse’s time is spent teaching others to
provide required care.

 Educator

The educative role of the home health nurse focuses on illness care, the
prevention of problems, and the promotion of optimal wellness or well-being.
Education is ongoing and can be considered the crux of home care practice; its goal is
to help clients learn to manage as independently as possible. All home health nurse
need to be skilled in teaching and learning principles and strategies that facilitate
learning.

Being an educator or teacher is an important and primary role for the nurse.
Clients and families have the right to health education in order to make informed
decisions about their health. The nurse is in a position to promote healthy lifestyles

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 through the application of health knowledge, the change process, learning theories
and the nursing and the teaching process when teaching clients and their families.

 Case Manager or Coordinator

The home health nurse coordinates the activities of all other home health team
members involved in the client’s treatment plan. Coordination can occur individually,
in person or by telephone, with a specific team member such as the dietitian or
respiratory therapist, or during a team conference where each team members provides
information about the client’s health status. The nurse is the main contact with the
physician or nurse practioner to report any changes in the client’s condition and to
bring about a revision in the plan of care as needed. Documentation of care
coordination is a legal and reimbursement and must be recorded on the client’s
medical record.

SELECTED DIMENSIONS OF HOME HEALTH NURSING

Selected dimensions of home health care include

 Safety Features
 Client Safety
 Nurse Safety
 Infection Control
 Caregiver Support

 Safety Features

 Client Safety

Hazards in the home are major causes of falls, fire, poisoning and other accidents such
as those caused by improper use of household equipment (e.g. tools and cooking
utensils). The appraisal of such hazards and suggestions for remedies is an essential
nursing function.

Obviously home health nurses cannot expect to change a family’s living space and
lifestyle. However they can express their concern and react appropriately when a
situation suggests that an injury is imminent. Nurses must document information they
provide and the family’s response to instruction, and make ongoing assessment about
the family’s use of safety precautions.

Home Care Assessment

Home Hazard Appraisal for Adults

Client and Environment

• Walkways and stairways ( inside and outside

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Not uneven sidewalks or paths, broken or loose steps, absence of handrails, congested
hallways or other traffic areas, and adequacy of lighting at night.

• Floors

Note uneven and highly polished or slippery floors and any unanchored rugs or mats.

• Furniture

Note hazardous placement of furniture with sharp corners. Note chairs or stools that are
too low to get into and out of or that provide inadequate support.

• Bathrooms

Note presence of graph bars around tubs and toilets, nonslip surfaces in tubs and shower
stalls, handheld showerhead, adequacy of night lighting, need for raised toilet seat or
bath chair in tub or shower, ease of access to shelves and water temperature regulated at
a maximum of 49 degree(120 degree F).

• Kitchen

Note pilot lights (gas stove) in need of repair, inaccessible storage areas, and hazardous
furniture.

• Bedrooms

Note adequacy of lighting, in particular the availability of night- lights and accessibility
of light switches, ease of access to commode, urinal, or bedpan, and need for hospital
bed or bed rails.

• Electrical

Note unanchored or frayed electrical cords and outlets that are overloaded or near
water.

• Fire Protection

Note presence or absence of smoke detectors, fire extinguisher, and fire escape plan,
improper storage of combustibles (e.g. gasoline) or corrosives (e.g. rust remover)

• Toxic Substances

Note improperly labeled cleaning solutions.

• Medications

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Note medications kept beyond date of expiration, adequacy of lighting for medication
cabinet or storage, and method of disposal of sharp objectives such as needle used for
injections.

• Communication devices

Note presence of method to call for help, such as a telephone or intercom in the
bedroom and elsewhere (e.g. kitchen), and access to emergency telephone numbers.

Other aspects of client safety relate to emergency situations. The home health nurse can
assist the client and caregivers as follows:-

• Post a list of emergency telephone numbers (ambulance, fire, police, and

physician) at each telephone.
• Post a list of all the client’s medications and potential side effects in a central
location, such as on the refrigerator.
• Help the client and family apply for a medical alert system such as bracelet or
necklace.
 Nurse Safety

Some less desirable living locations pose additional safety concerns for the
nurse. Many home health agencies have contracts with security firms to escort nurses
needing to see clients in potentially unsafe neighborhoods. The nurse should avoid
taking any personal belongings during these visits and have a reestablished mechanism
to signal for help. Home health agencies provide training for nurses in ways to decrease
personal risk.

 Infection Control

The goal of infection control is to protect the clients, caregivers and the general
community from the transmission of disease. This is particularly important for clients
who are immuno compromised, who have infectious or communicable diseases, or who
have draining wounds, drainage tubes, or other invasive access devices. The nurse’s
major role in infection control is health teaching. Clients and caregivers need to learn
about effective hand washing, use of gloves, handling of linens, disposal of wastes and
soiled dressings, and the practice of infection control (standard precautions). Infection
control can present a challenge to the home health nurse, especially if the home care
An important aspect of infection control involves handling the home health nurse’s
equipment and supplies. Supplies may include materials for hand washing, assessment
equipment such as stethoscope, blood pressure cuff and monitor, thermometer, and tape
measure, infection control items such as gowns, goggles, masks, gloves, and blood spill
kit, and antimicrobial cleaning agents. Nurses need to follow agency protocol in regard
to aseptic practice with these.

 Caregiver Support

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Care giving may be directed to individuals of any age and varies from short term to
long term according to the physical or mental disabilities of the care receivers.
The home health nurse needs to recognize signs of caregiver role strain and suggests
ways to minimize or alleviate this problem. Signs of caregiver overload include the
following.

 Difficulty performing routine tasks for the client.

 Reports of declining physical energy and insufficient time for care giving.
 Concern that care giving responsibilities interfere with other roles such as those
of parent, spouse, work, friend.
 Anxiety about ability to meet future care needs of client.
 Feelings of anger and depression.
 Dramatic change in the home environment’s appearance.

APPLYING THE NURSING PROCES IN THE HOME

The application of the nursing process is focused on the needs of individual clients and
their caregivers. The nursing process is used to identify, diagnose and treat human
responses to health and illness. The skills required for nursing process are as follows:-

 Cognitive/ intellectual skills

 Interpersonal skills
 Technical skills

Nursing Management

The elements or steps of nursing process are:-

 Assessment(of client’s problem)
 Diagnosis ( of client response needs that nurse can deal with)
 Planning ( of client’s care)
 Implementation (of care)
 Evaluation (of the success of implemented care)

Assessment
Diagnosis

NURSING PROCESS

Evaluation Planning

9 Implementation
 Assessment(of client’s problem)

The home health nurse assesses not only the health care demand of the client and family
but also the home and community environment. Assessment actually begins when the
nurse contacts the client for the initial home visit and reviews documents received from
the referral agency. The goal of the initial visit is to obtain a comprehensive clinical
picture of the client’s need.

Most agencies have an admissions or intake packet that includes forms for consent to
treatment, physical, psychosocial, and spiritual assessments, medications, pain
assessment, family data, financial assessment including insurance verification, client’s
bill of rights, care plan and daily visit notes. During the initial home visit, the home
health nurse obtains a health history from the client, examines the client, observe the
relationship of the client and caregiver, and assess the home and community
environment. Parameters of assessment of the home environment include client and
caregiver mobility, client ability to perform self care, the cleanliness of the
environment, the availability of caregiver support, safety, food preparation, financial
supports and the emotional status of the client and caregiver.

 Diagnosis ( of client response needs that nurse can deal with)

As in other care environments, the nurse identifies both actual and potential client
problems. Examples of common nursing diagnoses for home care include Deficient
Knowledge, Impaired Home Maintenance, and Risks for caregiver Role strain. Client
education is considered a skill reimbursed by Medicare and other commercial insurance
carriers, it is important for the nurse to include Deficient Knowledge in the plan of
care .The deficit in knowledge may relate to client’s lack of information about their
disease process, medications, self- care skills and so on.

 Planning ( of client’s care)

During the planning phase the nurse needs to encourage and permit client’s to make
their own health management decisions. Alternatives may need to be suggested for
some decisions if the nurse identifies potential harm from a chosen course of action.

Strategies to meet the goals generally include teaching the client family techniques of
care and identifying appropriate resources to assist the client and family maintaining
self-sufficiency.

 Implementation (of care)

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To implement the plan, the home health nurse performs nursing interventions, including
teaching, coordinates and uses referrals and resources, provides and monitors all levels
of technical care; collaborates with other disciplines and providers; identifies clinical
problems and solutions from research and other health literature, supervises ancillary
personnel, and advocates for the client’s right to self –determination. Technical skills
commonly performed by home health nurses include blood pressure measurement; body
A large part of the nurse’s implementing role involves teaching the client and caregiver
the necessary skills for self care- for example, administering insulin injections,
measuring blood glucose, and administering medications. Medication instruction about
dosage, frequency of administration and possible side effects is of particular concern for
many clients. The clients who are receiving high technology interventions are often
anxious about their ability to manage such sophisticated equipment. The home health
nurse is challenged to alleviate the client’s fears and to provide through instructions and
demonstration and periodic evaluation of the client and family’s performance of such
skills. Members of the home care team specially trained in the skill such as intravenous
nurses and respiratory therapists, generally make periodic visits to service the
equipment and to monitor the client’s skills.

 Evaluation and Documenting (of the success of implemented care)

Evaluation is carried out by the nurse on subsequent home visits, observing the same
parameters assessed on the initial home visit and relating findings to the expected
outcomes or goals. The nurse can also teach caregivers parameters of evaluation so that
they can obtain professional intervention if needed. Documentation of care given and
the client’s progress toward goal achievement at each visit is essential. Notes also may
reflect plan for subsequent visits and when the client may be sufficiently prepared for
self care and discharge from the agency.

THE FUTURE OF HOME HEALTH CARE

What is the future for home health care? Experts in the home health care industry have
identified some trends:

 Establishing ethics committees to handle ethical issues that arise in the home. These
committees may be necessary for agencies to receive accreditation.
 Providing third party reimbursement for community clinical nurse specialists and
psychiatric nurse specialists. These advanced practice nurses can provide education,
support, counseling and therapy for clients and their families.
 Providing third party reimbursement for social workers. Social workers can assist
clients and their families in the home with financial and household problems,
freeing the nurse to focus on nursing care.
 Utilizing nurse pain specialists to assess and manage pain in the home, thus
avoiding costly hospitalizations and procedures.
 Providing pet care for clients who may become too ill to care for them. Clients can
make arrangements for the care of a pet if they are hospitalized or die.

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 Utilizing electronic home visits. A computerized system can obtain information,
such as blood pressure readings, allowing case managers to review a client’s
progress from offsite.

A. FAMILY NURSING

DEFINITION

Family
“Family is a social group characterized by common residence, economic
cooperation and reproduction. It includes adults of both sexes, at least two of whom
maintain a socially approved sexually relationship and one or more children.”

- Murdock GP 1965

“Family is the co-existence of more than one human being involving continuous
presumably permanent sharing of living facilities, a perception of reciprocal
obligations, a sense of commonness, and sharing of certain obligations towards others.”

- Mauksch 1974
“

DEFINITION AND MEANING

Family Health Nursing

Family health nursing aspects of organized family health care services which are
directed or focused on the family as the unit of care with health as the goal.

Family health nursing is thus synthesis of nursing care and health care. It helps to
develop self care abilities of the family and promote, protect and maintain its health.
Family health nursing is generalized, well balanced and integrated comprehensive and
continuous are requiring comprehensive planning to accomplish its goal. Family health
nurse works with the family with co- operation and active participation to help deal
with its health needs and health problems effectively. The family is considered capable
to deal with its health needs and health problems effectively when the family is able to:-

 Maintain home environment conducive to personal development and health

promotion.
 Recognize its health needs and presence of any health problem.

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  Make decisions about appropriate actions.
 Provide care to the sick, disabled and dependent members of the family.
 Maintain wholesome reciprocal relationship with the community and family.

In family health nursing, the primary concern of community health nurse is to help
family develop and strengthen these abilities and give care until the family is not able to
do so. The nurse makes use of nursing process in helping family meet its health needs
and solve health problems.

OBJECTIVES OF FAMILY HEALTH NURSING

 To identify health and nursing needs and problems of each family.

 To ensure family’s understanding and acceptance of these needs and problems.
 To plan and provide health and nursing services with the active participation of
family members.
 To help families develop abilities to deal with the health needs and health problems
independently.
 To contribute to family’s performance of developmental functions and tasks.
 To help family make intelligent use of promotive, preventive, therapeutic and
rehabilitative health and allied facilities and services in the family and community.
 To educate, counsel and guide family members to cultivate good personal health
habits, practice safe cultural practices and maintain wholesome physical,
psychosocial and spiritual environment.

GOALS

 To help the family and its individual members reach and maintain maximum health
through out and beyond the illness experience.

PRINCIPLES OF FAMILY HEALTH NURSING

 Family health nursing is family focused, it is therefore essential to know the family
from various aspects which include family structure and characteristics,
socioeconomic and cultural factors, environmental factors and health and medical
history of family members. Various methods are used for collecting information
from the family. The data has collected are analysed and health needs and health
problems are identified and prioritized.
 Must establish good working relationship with the family. A good working
relationship helps the nurse and the family knows each other and work together to
plan, implement and evaluate family health and nursing care. Thus it helps in
achieving family health goals and objectives. Working relationship is developed by
knowing the family, giving due respect in culturally acceptable ways, listening to
them, communicating intentions to help and the nature of help that can be extended,
meeting their immediate felt need, considering their views and opinions etc.

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 Family health nursing is part of family health care services and based on identified
family health and nursing needs. The community health nurse working in
community health settings needs to know family health care policies, goals,
objectives and the nature of family health care services. Accordingly she needs to
plan and provide family health nursing services with active participation of the
family members.
 Family health nursing services should be realistic in terms of resources available.
This requires proper estimation of health needs, health problems and resources in
terms of money, manpower, material and time, prioritization of health needs/ health
problems, mobilizing and developing more resources.
 Family relates to community where it lives and depends on community in various
ways. It is therefore essential to attain working knowledge of the community to help
family to develop favorable attitude towards community and utilize community
resources. She can also encourage families to contribute towards community health
and welfare by active participation in such activities in the community.
 Family as a unit is responsible for their members’ health and has a right to make
health care decisions. Therefore, family must fully participate in all decision making
relating to attainment of health. The community health nurse must recognize and
respect this right and encourage active participation of the family in making health
care decisions.
 Health education, guidance and supervision are integral part of family health
nursing. Information, education, guidance and supervision are very important
because these help family to improve knowledge, develop competences, create
interest and become self dependent. These elements must be included in the family
health nursing care plan and implemented accordingly.
 Continuous services are effective services. The community health nurse must
maintain continuous contact with the family and provide care not only when the
family is sick but also to promote and maintain health and prevent diseases etc.
 Effective system of record and report of family health nursing service is essential.
Proper maintenance of family health nursing record serves effective means for
continuous care and its evaluation and further planning. Records must give
information about family’s structure and characteristics, family environment, socio-
economic and cultural factors, health and medical history of all members. It should
give informations about health care planned, care implemented, objectives achieved,
problems encountered and summary evaluative report over some period and
suggestions for further plan.
 Periodic and continuous appraisal and evaluation of family health situation and
health services are basic to family health nursing care. Family is dynamic. It grows
and develops with time and changes with place. The health needs and problems
keep changing from time to time. These changes need to be assessed as the family
grows and develops through various stages of development. This helps in meeting
changing needs of the family.
Evaluation of health and nursing care rendered is done on the basis of objectives,
care planned and implemented and recorded. Evaluation gives feedback for further
planning.
 Family health nursing services should be rendered to all families without any
discrimination. Every family has a right to attain optimum health and an
environment conducive to healthful living so as to lead productive and useful life.
Every family contributes to health of the community. Therefore family health

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 nursing services should be available to all families based on their health needs and
health problems.

ADVANTAGES OF FAMILY HEALTH NURSING

 Family health nursing of patients saves hospital beds that can be utilized for critical
cases.
 Family health nursing is cheaper than hospital nursing.
 Patient under family health nursing enjoys privacy and emotional support.
 Patients on family health nursing can continue with their routine pursuits.
 If the patient resides in a sanitary house, family health nursing is better than hospital
nursing since he can control inimical environmental influences better.

DISADVANTAGES OF FAMILY HEALTH NURSING

 Family health nursing requires the nurse to carry portable laboratory machinery to
the patent’s home.
 If the patient resides in a substandard house, family health nursing could delay his
recovery.

RANGE OF FAMILY HEALTH NURSING SERVICES

 Therapeutic

The nurse carries out treatment of the patient as per the instructions of the physician.

 Prognostic

The nurse notes the progress or lack of it in the patient’s condition and provides
feedback to the physician.

 Nursing care proper

The nurse helps the patient with feeding, dressing, application/ change of dressing or
bandages, and so on, depending on the nature of illness.

 Educative

She educates the patient and the family about the disease, its causes, treatment and the
measures to avoid contracting it. She trains the family in caring for the patient.

 Counseling
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The nurse counsels the patient and assists him cope with physical and psychological
complications of the disease. She helps the patient develop a positive and optimistic
attitude.

 Social assistance

Where necessary, the nurse arranges with the welfare organizations in the community to
provide assistance in cash or kind to the patient.

 Family diagnosis

The family health nurse assesses the interactions between the patient and the family
members. If she finds these are adverse and delaying patient’s recovery, she tries to
correct them through suitable counseling
APPROACHES TO FAMILY NURSING PRACTICE

There are four approaches or ways to view families that have legitimate implications for
nursing assessment and intervention. The approach that nurses use is determined
circumstances, and nurse resources. The four approaches included in the family health
nursing care views are:-

 Family as the context

 Family as the client
 Family as a system
 Family as a component of society

 Family as the context

When the nurse views the family as context, the primary focus is on the health
and development of an individual member existing within a specific environment (i.e.,
the client’s family).Although the nurse focuses the nursing process on the individual’s
health status, the nurse also assesses the extent to which the family provides the
individual’s basic needs. These needs vary, depending on the individual’s development
level and situation. Because families provide more than just material essentials, their
ability to help the client meet psychological needs must also be considered. Family
members may need direct interventions themselves.

 Family as the client

The family is the foreground and individuals are in the background. The family
is seems as the sum of individuals family members. The focus is concentrated on each
and every individual as they affect the whole family. From this perspective, a nurse
might ask a family member who has just become ill. Tell me about what has been going
on with your own health and how your perceive each family member responding to
your mother’s recent diagnosis of liver cancer.

When the family as client is the approach, family process and relationships (e,
g.parenting or family care giving) are the primary focuses of nursing care. The focus of

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nursing assessment is usually on family patterns versus individual characteristics. The
nursing process concentrates on the extent to which these patterns and processes are
consistent with reaching and maintaining family and individual health.

 Family as a system

The focus is on the family as a client and it is viewed as an international system

in which the whole is more than the sum of its parts. This approach focuses on the
individual and family members become the target for nursing interventions. For
example, the direct interaction between the parent and the child. The system approach
to the family always implies that when something happens to one affected.

It is important to understand that although theoretical and practical distinctions

can be made between the family as context and the family as client, they are not
necessarily mutually exclusive, and both are often used simultaneously, such as with the
perspective of the family as system.
 Family as a component of society

The family is seen as one of many institutions in society, along with health,
educational, religious, or economic institution. The family is a basic or primary unit of
society, as are all the other units and they are all a part of the larger system of society.
The family as a whole interacts with other institutions to receive exchange or give
communications and services. Community health nursing has drawn many of its clients
from this perspective as it focuses on the interface between families and communities.

 Improvement in the functioning of an individual will elicit improvement in the

functioning of the whole family.
 Because of the systematic nature of family, interventions can be directed at any
of several levels with a resultant change in family operation.
 The nature of the nurse client interaction is a crucial part of family nursing
intervention.
 Family nursing intervention needs to be modified to match different family
needs, family styles, and levels of family functioning.

STEPS IN FAMILY HEALTH NURSING

a. Pre-visit Planning

Before making home visit, the nurse finds out the following:
 Address of the patient, including the near by landmarks.
 Information on the patient’s family.
 Information about the supportive services in the community.

b. Visit Proper

On the day of the visit, the family health nurse takes precautionary care against possible
robbery by not putting on gold ornaments, by not wearing costly wrist watch, and by

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not carrying her money purse. She verifies her identify card is in her purse. While going
to the patient’s house she avoids lonely lanes and deserted roads.

c. Commencement of Family Health Nursing

On reaching the client’s home, she introduces herself after greeting the patient and his
family with folded hands. She explains the purpose of her visit. She creates trust in
them and establishes rapport with them. She projects herself as a knowledgeable and
competent person. This way she can ensure their cooperation and respect. She then
interrogates and examines the patient. She enters the findings in the patient.

d. Termination of Family Health Nursing

When nursing has concluded, the family health nurse fixes a date and time of her next
visit. If, however, the patient’s condition has improved considerably, she announces she
would not be visiting again.

FAMILY HEALTH NURSING PROCESS

Family health nursing process is a systematic approach to help family to develop and
strengthen in capabilities to meet its health needs and solve health problems. It is
deliberate process which facilitates standardized nursing actions to achieve family
health nursing goals and objectives. The nursing process makes use of investigative
approach to identify health needs and health problems and hypothetical solutions to
identified problems. It is a tool which can be implemented at primary, secondary and
tertiary level of care.

Family health nursing process is a problem solving and follows series of systematic
steps to analyze health problems and find their solutions. Whether the problem is simple
or complex, the process remains the same.. The process helps in providing systematic
need based comprehensive health care services to the entire family within the resources
available with their active involvement. It helps in achieving desired goals of health
promotion, prevention and control of health problems.

Nurses interact with families in a variety of community based and clinical

settings. The nurse uses the nursing process to care for an individual within a family
(e.g. the family as a context) or the entire family (e.g. the family as the client). When
initiating the care of families, there are three factors that organize the family approach
to the nursing process.
 That all individuals must be viewed within their family context.
 Those families have an impact on individuals.
 That individual has an impact on families.
The nursing processes are as follows:-
A. Establishing a working relationship
B. Assessment of health needs
C. Planning for nursing action
D. Implementing the programme
E. Evaluation of programme action

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Steps of Family Health Nursing Process

A. Establishing a working relationship

B. Assessment of health needs
 Data collection
 Personal history
 Family history
 Home and environmental history
C. Planning for nursing action
 Goal setting and selection of appropriate strategy
 Formulation of nursing diagnosis
 Resources available
 Alternative plan of action
D. Implementing the programme

E. Evaluation of programme action

 Formative
 Summative

A. Establishing a working relationship

The family and nurse maintain a working relationship. It is relationship which is

maintained while working together by developing trust, confidentiality and empathy.
These are essential components or elements to find out the facts from families and
making correct decisions. A working relationship must have scope of two way
communication. The family members must be given equal opportunity to give their
views and ideas and express the feelings and vice versa. The nurse must have enough
interactions with family members to guide and help them to solve the problem.

B. Assessment of health needs

Assessment is primarily concerned with first level or initial assessment which helps to
know and explore family and health needs/ health problems and it refers to family
identification. Assessment is a continuous process which becomes more accurate as
knowledge of people deepens. As defined by Heparin,

“Nursing assessment is a continuous, systematic, critical, orderly analyzing and

interpreting information about physical, psychological and social needs of a person, the
nature of self care deficient and other factors influencing condition and care.”

 Data collection

Collection of basic information – the information regarding family composition is

collected about each family member’s name, age, sex, educational level, marital status,
occupation and health status.

Methods of data collection

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The information can be collected by various methods at home:

• Observation

The family health nurse must be good observer, during home visit. Collection of
information by observation gives realistic situation of health practices. Observation of
home environment (physical, psychological and economical) and living condition will
help to assess the general condition. Interpretation of the data will help for nursing
interventions.

In family health nursing certain situations need direct observation. It is important to get
acquainted with family/ environment along with patient and many things can be learnt
by observation.
e.g., in a family how mother holds the infant, the feeding techniques and how safe the
environment is for child to prevent from hazards and the cooking methods for food
hygiene can only be done by home visiting and observation. Interpersonal relationship
of husband and wife, mother- child can be observed and make interpretations to find
different health problems

Interviewing

Interviewing is a face to face conversation with a purpose. Interview is a method of

securing information such as facts, opinion and personal history. Through interview
process an individuals can mutually clarify feelings, attitudes and meaningful
information. In this way family health nurse can gain increased understanding of
behaviour and personal reactions of individual they serve. Thus, interview process can
help individuals to recognize and understand their own problems.

Any type of successful interview includes a satisfactory environment, privacy and

assurance of confidentiality. The home is suitable place for the community health
nursing to interview the clients, especially when she has to interview for the first time,
as the client will feel more comfortable, secure and relaxed in her own environment.
Interviews can also be conducted in the clinics, offices, health centers and the place of
work.

Techniques of data collection

Family health nurse should have the knowledge of various techniques of data collection,
which can be used to collect information on family health, family environment and
other factors affecting health of families. The techniques/ tools used can be:-

• Questionnaire
 Structured
 Unstructured
• Observation checklist
• Rating scale
• Interview schedule
 Structured

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  Unstructured

Assessment of Health Problems

Health problems can be identified into three categories:-

 Health Deficits

Health deficits refer to instances of failure in health maintenance and development.

Health deficits includes:-

• Diagnosed/ suspected illness states of family members

• Sudden or premature or untimely death illness or disability and failures to adapt
reality of life emotional control and stability.
• Deviations in growth and development
• Personality disorders.

 Health Threats Practices

Health threats refers to conditions which predispose to disease, accident, poor or

retarded growth and development and personality disorder and a failure to realize one’s
health potentials. The possible health threats are as under:-
• Large family size
• Lack of/ inadequate education
• Ignorance
• Immature parents
• Strained family relation, conflicts, inappropriate role distribution
• Broken family/ single parent family
• Family history of congenital/ hereditary problems
• Unbalanced diet, improper dietary practices
• Poor hygiene and health practices
• Previous history of illness and obstetrical conditions
• Incomplete/ lack of immunization
• Strange/ inadequate relations with neighbourhood/ community
• Poor environmental conditions
• Inadequate housing facility
• Inadequate basic amenities
• Poor sanitation
• Environment pollution
• Accident hazards
• Unsafe water supply

 Foreseable Crisis or stresses

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Foreseable crisis situations or stress points, refers to anticipated periods of unusual
demands on the individual or the family in terms of adjustment or family resources.
These possible foreseeable crisis situations and stress points are as under:-

• Marriage
• Pregnancy, labour, postnatal period, abortion, miscarriage
• Additional members in the family
• New born, guests
• Developmental stages
• New jobs, loss of jobs, retirement
• Death
• Menopause
• Change of residence

C. Planning for nursing action

 Goal setting and selection of appropriate strategy

A good assessment will make the selection of appropriate goals and strategies easier.
Families determine the degree of change required. Often people can easily identify their
own goals. However community health nurse has to assist in making a clear goal
statement by achievable means. Be sure that neither community health nurse nor
families are too ambitious. Goal should be clear and concise statement. Clearly written
goals give a sense of direction in how to proceed in the care of the family. This
increases the self confidence and trust and confidence of the family in you and your
ability to provide care.

A goal must state a measurable outcome. This gives you the tool for determining
whether or not your goal has been achieved. It is important to state one measurable
outcome per goal. It helps you to keep the desired outcome separately and can be
measured easily. There are three types of goals. They are as follows:-

Immediate Goals

The goals which require action within a short period of time as per need and crisis in the
family. One of the positive effects of setting and achieving and immediate goal is that
the nurse and the client will both feel a degree of satisfaction and sense of
accomplishment because it has been achieved. This also gives confidence to both nurse
and the family, as they continue towards the achievement of their short and long term
goals.

E.g. If the mother starts antipartum haemorrhage, you have the immediate goal to care
the mother with APH to save the life of mother and fetus.

Short Term Goals

The goals that are to be achieved over a specific period of time. These are the steps
towards achievement of long term goals. They have specific time limit to accomplish
the goals through in certain circumstances they may be some variation in time.

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E.g. For mother, the long term goal is that she produces a healthy baby and she remains
healthy till the end of the delivery and even after delivery. To achieve this goal various
short-term goals are established like to assess the general condition, to do the
investigation, regular antenatal check up and give health education etc. These short term
goals have specific time period to achieve them.

Long-term Goals

The goals that are oriented towards the future and state the ultimate level of health care
can be achieved. It is important that goals are realistic in order to achieve them.
Unrealistic goals can lead to frustration, discouragement and waste of all efforts
towards maximum health.

After assessment, the ultimate or long-term goals must be set as to what has to be
achieved to keep the health status of the family.

The nursing needs which do not require immediate attention or action, the goals can be
set as late priority than immediate or short term goals.

E.g. A child having diarrhea requires immediate action to teach for oral rehydration
solution (ORS) supplementation and control diarrhea is an immediate goal and
providing immunization and health status to child is long term action or can be taken
laterin long term, where the nurse will find the result in later stage. Hence the has to
prioritise short and long term goals to provide efficient and effective health care to
family.

Development of strategy

In many stances there may be more than one possible course of action that appear
suitable to the solution of the problem. Community health nurse must look for all
possible ways of accomplishing a goal, make a selection. Along with the family select
the strategy which you feel will best serve to achieve the goal. Once it has been
selected, then review the reason for the choice made and record the rationale. Do not
discard the other strategies which might be helpful further.
After selection of strategy, choose one or two alternatives, so that you can choose
another one, if initial fails. Record the strategies together with the goals set. These
strategies and alternatives must be discussed with family members.

These strategies become successful, when the family is encouraged to take the
responsibility for selecting a course of action, even though the action selected may be
less productive than one the nurse would have chosen. But it enhances the ability of
family to make decisions and solve their own problems in health matters.

 Formulation of nursing diagnosis

Once assessment is complete, review all the data, compile the risk factors and formulate
nursing diagnisis.Since assessment is an ongoing process, it should be periodically
reviewed, deleted and revised as per need. It is important to look at assessment data in
totality and compile as overall functioning and health of the family.

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The final step of family assessment is formulation of nursing diagnosis. The nurse, who
practices in the community just like those practicing in other health care settings,
formulates nursing diagnosis based on assessment data with complete data available.
She can formulate more accurate and scientific diagnosis. This forms the foundation for
development of a health care plan.

 Resources available

Availability of health related resources and financial resources used by family

members. Sometimes families need help in identifying these resources; they may not
define as broad as community health nurse can do.
Discussing the family’s financial status may be difficult initially, and family may be
reluctant to disclose their finances, to a stranger. The community health nurse must be
sensitive to such possibilities. The primary reason to know financial resources is to
know whether or not they are to meet their basic needs and able to meet the needs
during crisis. It is important to know the significance of strengths and weaknesses
related to resources. Sources of the family’s income must be noted whenever possible.

 Alternative plan of action

D. Implementing the programme

Implementation of nursing process in family health care is foundation of nursing

practice. Nurse uses family health care process to promote the health of families and
differentiate from work with individual events. Implementing the health care requires
home visits, working closely with families, community leaders, health workers, and
other related agencies like social welfare and educational institution, etc. for
comprehensive system to care.

Implementation is an ongoing process. Implementation of nursing care includes all

activities that community health nurse undertaken to carryout the nursing care plan
designed to improve the health of family and individual. In case of crisis situation in
family, she should be prepared to crisis intervention by helping on appropriate
resolution.

Implementing a nursing care plan implies that a careful assessment and planning
process has been accomplished. After goals and strategies have been set-up family is
ready to implement the plan. At the beginning the family is ready to implement the plan
and may be enthusiastic and eager to accomplish the goals. The role of nurse is to be
supportive and advocating these positive behaviours.

As the implementation process goes on, it may be necessary to change or omit certain
strategies according to situation. Nurse can also facilitate the growth of the well-
planned programme. Family’s satisfaction serves as the stimulus for adding further
goal. Sometimes nurse observes the family’s readiness and raises the possibility of care.

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E.Evaluation of programme action

“Evaluation is a process by which results are compared with the intended objectives or
more simply the assessment of how well a programme is being performed.” Evaluation
should be always considered during planning and implementation of programme or
activity. Planning and evaluation must be viewed as an interactive process leading to
continuous modification both of objectives and plans.

Evaluation of the family problems resolution and nursing strategies for interventions
occurs throughout the nurses’ contact with families and at the point of terminating the
relationship.
Evaluation is not an end to family health care programme, it is continuing process
integrated in the other phases. The ultimate goal of community health nurse is for the
family to be self- supporting and independent in identifying the presence or absence of
preventive health behaviour and skills in determining strategies and using appropriate
resources.

The nurse should observe for change in attitude during and after the intervention of
care. If she notices the failure brings to the desired change, then she needs to go back to
reset the objective, replan and reimplement the programming.

Types of Evaluation

a) Formative

Formative type of evaluation evaluates family health and nursing care plan as it is
planned and implemented to determine its strengths and weaknesses at each stage and
its progress towards meeting its objectives. As the plan is implemented, the community
health nurse evaluates the family’s and or individual member’s response to determine
the effectiveness of the actions planned and implemented and accordingly identify the
need for change and or modify the nursing care plan. Formative evaluation is ongoing
evaluation of day to day progress towards meeting health goals.

b) Summative

Summative type of evaluation concludes the progress or lack of progress towards the
goal after several objective based actions are implemented. The reasons for the same are
identified and modified and further actions are suggested.

Tools of Evaluation

These scales are used to elect the opinion, behaviour and attitude towards healthy
practice. The tools which are used are as follows:-

 Questionnaire

It is a tool in which the questions are formed in predetermined fashion, which are to be
filled up by the respondents. Questionnaire can either be closed (yes/No response) or
open ended (response from people)

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 Interviewing Schedule

A tool for responses which are recorded simultaneously. It can be structured or

unstructured. It is useful to get responses from illiterate people when written
questionnaire is not possible.

Techniques of Evaluation

 Questioning

The questionnaires are prepared to evaluate the programme. The questions are asked
verbally for the programme participants who are illerate and or are unable to read and
write and responses are recorded, tabulated, analysed and interpreted to find the impact
of the programme.

 Pen-pencil Technique
The questionnaires are given to programme participants to get the responses and
interpret the results to evaluate the effectiveness of the programme. The technique is
limited to educate people only.

 Observation Technique

 It is effective tool in community health, because many things can be interpreted

by observational skills, while tally which may not be interpreted by persons like
housing condition and sanitation, breastfeeding practices and child care etc.
Observer must develop the skills of accurate and correct observation and timely
recording. If good observation is made it gives an effective information
regarding health, which can supplement to the interview or questionnaires. The
opinionnaire is used to find the opinion of people regarding satisfaction level of
health services available and helps to improve the health care facilities.
 The observation checklist is prepared on the items to be observed, e.g., housing
conditions
Child care
Food hygiene
Demonstration of Oral Rehydration Therapy (ORT)

 Interviewing

It is a direct conversation between interviewer and interviewee. In interviewing the

interviewer asks a set of questions to the interviewee and gets responses on the
interview schedule (prepared before hand) and the responses are recorded
simultaneously.

NURSE’S RESPONSIBILITY IN FAMILY HEALTH CARE

26
 The promotion of health care of families is a unique responsibility of a nurse.
 Nurses help them to identify the weaknesses.
 The nurse must be able to assess the family as a unit of health service of an integral
part.
 The nurse should functions as a problem solver, resource link and health educator to
promote family health.

BARRIERS TO FAMILY HEALTH CARE

 Multiproblem family and difficult to prioritise the needs.

 Barrier to change: - The family may not understand to the concept of need.
 Language may be barrier, especially in rural population. They may not understand
the community health nurse’s language.
 Sociocultural: - The cultural of a family might interfere in providing family health
care. Hence, community health nurse needs to study such cultural and social
patterns and adjust to those and try to remove such barriers by assurance.

CHALLENGES FOR FAMILY NURSING

Delegation in the management of nursing care activities can become a challenge

in family nursing. Often nurses are trying to make an impact on family health by
delegating duties to family members or to other members of the health care team. For
example the nurse helps family members learn
how to provide certain types of procedures to care for an ill family member. With
earlier discharge and more complex family needs at the time of discharge, planning for
discharge begins with the initiation of care by the registered nurse.

Discharge planning with a family involves an accurate assessment of what will

be needed for care at the time of discharge, along with any shortcomings in the home
setting. For example, if a postoperative client will be discharged to the home and the
older adult husband doesn’t feel comfortable with the dressing changes required, the
nurse first finds out if there is anyone in the family or neighborhood who would or
could do this. If not the nurse arranges for a home care service referral. If the clients
also need exercises and strength training, then perhaps a physical therapy referral is
required.

Cultural sensitivity in family nursing requires recognizing not only the diverse
ethnic, cultural, religious backgrounds of clients, but also the differences and
similarities with in the same family. In family centered care, nurses learn how to
integrate cultural practices, religious ceremonies, and rituals into family centered care.
Using effective and respectful communication techniques enables the nurse to

27
determine the family’s cultural practices and collaborate with the family to determine
how best to integrate these beliefs and practices with in the prescribed health care
regimen.

CONCLUSION

“Family health nursing is the practice of nursing directed towards maximizing

the health and wellbeing of all individuals within in a family system. It incorporates two
views of family, family as a unit of care and family as a contact. Family health nursing
views the family as a system existing within larger system. Levels of intervention are
the individuals the personal, the family system, and the environmental level. The goals
of the family health nursing include optimal functioning for the individual and for the
family as a unit.”

.
JOURNAL RESEARCH ABSTRACT

“Family Nurse Practitioner is a nurse who has received additional education and
training necessary to function in the role of a primary care provider, performing many
of the same tasks as a family doctor. In India, 80% of the health facilities are
concentrated in urban areas. The rural areas where nearly 74% of the populations live
do not enjoy the benefits of modern curative and preventive health care services. There
is concentration of doctors’ upto 73.6% in urban areas where only 26.4 % of the
population live. In the college of Nursing Community Health Programme (CONCH),
Christian Medical College, Vellore, nurse run clinics are conducted by community
Health Nurses with some experience. They examine, diagnose and prescribe treatment
for the patients in the programme area as per standing orders. This research study was
undertaken to study the extent to which the nurse in the role of a family nurse
practitioner meets the primary care needs of the people and do recommend additional
preparation needed by the nurse to function as a family nurse practitioner. The study
revealed that the graduate nurses need additional preparation to function as family nurse
practitioners in the field of community health.”

BIBLIOGRAPHY

 Barbara Kozier Glexora Erb Audrey Berman Shirlee Snyder, “Fundamentals of

Nursing” (Concepts process and practice), 7th edition, chapter- 9,Home Care,
published in Indian by Saurabh printers pvt.Ltd,published by Pearson Education
(Singapore) pvt.Ltd, Indian Branch,482 F.I.E patparganj Delhi 110092, India,
2004,page no.-140- 151.

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  BT Basavanthapa, “Community Health Nursing”, 2nd edition, chapter-6,
Family Health Nursing, published by Jaypee Brothers Medical publishers, 2008,
page no.-108-136.
 Potter Perry, “Fundamental Of Nursing” 6th edition, chapter – 9, Caring for
Families, page no. - 140-152.
 Marcia Stanhope and Jeanette Lancaster, “Foundations of Nursing in the
Community” (community- Oriented Practice), 2nd edition, chapter-18, Family
Development and Family Nursing Assessment, published by Mosby Elsevier,
page no. - 321-339.
 Sunita Patney, “Textbook of Community Health Nursing”, First edition,
Chapter – 8, Family Health Care, published by Modern Publishers, 2005, page
no: 88-103.
 Krishna Kumari Gulani, “Community Health Nursing (Principles and
Practices)”, 1st Edition, Chapter-11, Maternal and Child Health, published by
Kumar Publishing House, 2005, page no.: 354 – 366.

JOURNALS

• Dr. Jayanthi Milka Bai, M.Sc. (N), Chellarani Vijayakumar,M.Sc (N),Ph.D,

Rosaline Jayakaran,M.Sc (N), Rajarathnam Abel, M.B.B.S, MPH, FICN., “Indian
Journal of Continuing Nursing Education”, Role of the community health nurse
as a family nurse practitioner January – December 2005, volume 6 , no. 2, page no:
24.

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